Death by post-mortem

It was the case of a pathologist at the Royal Infirmary which led the medical authorities to the probable source of the outbreak. Dr Norman Ainsley fell ill with a high temperature on 12 January and was admitted to Oakwell Isolation Hospital on the following day; he would die there on 23rd, despite receiving vaccination. His illness led the search back to a nine-year-old Pakistani girl who had died on Ward A1 at the Children’s Hospital on 30 December; the pathologist (who had never previously been vaccinated) had performed a post mortem examination on her body. The child’s father was living in Bradford and had recently travelled to Pakistan to bring his wife and daughter to join him. They had spent two weeks in Karachi, waiting for a flight to London; while there they went shopping and sightseeing. On 5 December all three attended a clinic to be vaccinated and received valid International Certificates. Both parents were later found to have scars indicating successful revaccination and the father reported that a few days after attending the clinic in Karachi his daughter’s arm became red, though no crust or scar developed. Described in the official report as ‘a reliable witness’, he also reported that she had been vaccinated as a baby.

The family arrived in London on late on 16 December 1961 and travelled to Bradford next day by train. On the 23rd, the girl was admitted to the Children’s Hospital with symptoms which looked like malaria. She seemed to respond to treatment and over Christmas there was no rise in her temperature. But on 29th her temperature rose to 103F; next day she died, having developed a few ‘petechiae’ on one side of her face and neck. The post mortem examination would cost the unvaccinated pathologist his life. He concluded that she died from ‘staphylococcal septicaemia’ and malaria. Smallpox was not identified – a fact which had deadly consequences. By the time the outbreak became apparent, it was no longer possible to confirm the source; the child’s body had been embalmed and sealed in a coffin before being flown back to Pakistan.

Importance of vaccination of medical staff

The deaths of the pathologist and the nurse from the Children’s Hospital, neither of whom had been vaccinated, prompted the authors of the official report on the outbreak to record a serious criticism of the standard of readiness in the hospital. The first lesson to be learned, they said was: ‘the absolute necessity to maintain the protection of hospital staffs by repeated revaccination as recommended in Hospital Memorandum R.H.B. (50)75.’ But this was not the only case in which a potentially vulnerable member of the medical profession failed to protect himself and, as a result, put many others at potential risk. It was the illness of a doctor who attended the autopsy on another ‘missed case’ in south Wales which raised the alarm about the Rhondda outbreak.

The nine-year-old girl in Bradford was the first ‘missed case’ of the 1962 smallpox outbreaks in Britain; as with the later outbreak in Wales, it had serious consequences – allowing the virus to spread before its presence in the area had been identified. But in Yorkshire, unlike Wales, it seems that all contacts were traced and the outbreak was contained by effective vaccination and monitoring of possible carriers.